Mod VI: Pediatric & Neonatal Anesthesia Emergencies Flashcards
Pediatric & Neonatal Anesthesia Emergencies
Pediatric Airway obstruction/emergencies
Epiglottitis
Laryngotracheobronchitis or “croup”
Foreign body aspiration
Pediatric & Neonatal Anesthesia Emergencies
Developmental anomalies
Choanal atresia
Congenital diaphragmatic hernia
Bronchopulmonary dysplasia
Meconium aspiration syndrome
Pediatric & Neonatal Anesthesia Emergencies
Common pediatric congenital intra-abdominal malformations
Esophageal atresia and Tracheal Esophageal Fistula
Omphalocele and gastroschisis
Pyloric stenosis
Necrotizing enterocolitis
Intestinal obstruction
Pediatric Airway Emergencies
Inflammation of the epiglottis—the flap at the base of the tongue that keeps food from going into the trachea (windpipe)
Epiglottitis
This is a Life threatening airway emergency!!!
Pediatric Airway Emergencies - Epiglottitis
Etiology of Epiglottitis:
Bacterial infection (Haemophilus influenza type B)
Epiglottitis is rare vaccination offers protection
Pediatric Airway Emergencies - Epiglottitis
Why is inflammation a/w Epiglottitis considered “Supraglottitis”?
Tissue from vallecula→ arytenoids are affected
Pediatric Airway Emergencies - Epiglottitis
Epiglottitis affect patients that are usually how old?
2-7 y/o
Pediatric Airway Emergencies - Epiglottitis
What’s the Clinical presentation of Epiglottitis?
Sudden onset high fever (>39 C)
Dysphagia
Drooling
Thick-muffled voice
Sitting with head extended leaning forward (Tripod Position)
Severe obstruction: stridor, retraction, labored breathing, cyanosis
Pediatric Airway Emergencies - Epiglottitis
What’s the hallmark clinical sign of Epiglottitis?
Tripod Position
Sitting with head extended leaning forward
Pediatric Airway Emergencies - Epiglottitis
Normal vs inflamamed epiglottis
See picture
Pediatric Airway Emergencies - Epiglottitis
Initial management of Epiglottitis
Administer 100% O2/ face mask
—
KEEP CHILD CALM!!!!
Allow parental presence
Avoid blood draws, IV starts, excessive manipulation before airway is secured
Do not place the child supine
—
Stable→ obtain lateral x-rays of soft tissue of neck
“thumb” sign
Epiglottitis confirmed or Airway compromised→ directly to OR
OR/ENT/Anesthesia must be notified and prepared completely
Have appropriate sized ET, blades, OA, pulse oximeter, Ambu bag/mask, portable suction& succinylcholine/atropine IM available during transport
TRANSPORT ONLY WITH ANESTHESIA /ENT SURGEON CAPABLE OF EMERGENCY AIRWAY MANAGEMENT
Pediatric Airway Emergencies - Epiglottitis
Stable→ obtain lateral x-rays of soft tissue of neck. What sign are you looking for?
“Thumb” sign
Outpouching of soft tissue towards the spinal cord
Should not be there normally on a healthy person
Indicates excessive swelling around the epiglottis
Pediatric Airway Emergencies - Epiglottitis
T/F: AT NO TIME SHOULD DIRECT VISUALIZATION OF EPIGLOTTIS BE ATTEMPTED IN AN UNANESTHETIZED PATIENT!!!!!!
TRUE
It’s very important to keep them calm and not hyperventilating
Make sure they are anesthetized before any direct airway visualization
Not following these guidelines could lead to total airway obstruction
Pediatric Airway Emergencies - Epiglottitis
Another view of the “Thumb” sign
See picture
Pediatric Airway Emergencies - Epiglottitis
Anesthesia considerations/management w/ Epiglottitis
Minimize manipulation of child
Remain in upright position
Precordial and pulse oximeter monitoring adequate
Allow parental presence until LOC of child
Gradual inhalation induction with sevoflurane & 100% O2 maintaining spontaneous ventilation
Avoid PPV if possible
Start IV with LOC/loss of lid reflex→ atropine if indicated
Tracheal intubation*
Pediatric Airway Emergencies - Epiglottitis
Tracheal intubation w/ Epiglottitis:
Deep inhalational anesthesia
O_ne size smaller ETT/Stylette_
Avoid muscle relaxants until airway established
LMA not useful!
All the swelling will still be south of the opening, and all of the obstruction will still be present => <u>Must use an ET tube</u>
Tracheostomy/cricothyroidotomy with l_ife-threatening hypoxia_
Pediatric Airway Emergencies - Epiglottitis
If unable to identify vocal cords, what can you do to ID airflow location?
Have the pt spontaneously ventilate still
Look for gas bubbles coming out
If pt apneic at this point, you could do gentle pressure on the pt’s chest to try to elicit a bubble; this may allow identification of airflow location
Pediatric Airway Emergencies - Epiglottitis
Postoperative management of Epiglottitis:
Continue mechanical ventilation
<u>Sedation</u> appropriate at this time
<u>Propofol</u>?? (consider “<strong>Propofol infusion syndrome</strong>”)
IV Antibiotics
Tracheal extubation*
Pediatric Airway Emergencies - Epiglottitis
Which criteria must be met before Tracheal extubation following Epiglottitis?
Significant leak around ETT is present and
Visual inspection of larynx by flexible bronchoscope confirms reduction in swelling
Attempted usually 48-72 hrs later
Pediatric Airway Emergencies
The type of respiratory infection that is usually caused by a virus. The infection leads to swelling inside the trachea, which interferes with normal breathing and produces the classic symptoms of “barking” cough, stridor, and a hoarse voice is also known as:
Laryngotracheobronchitis or “Croup”
Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”
Etiology of “Croup”:
Primarily viral
Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”
“Subglottic” narrowing in “Croup” is d/t:
Inflammation of subglottic tracheal mucosa and the entire tracheal bronchial tree
Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”
“Croup” is prevalent in which age group?
Occurs in children 6mos - 6y/o
Primarily seen < 3y/o
Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”
Clinical presentation of “Croup”:
More insidious than epiglottitis
Viral prodrome (URI)
Low-grade fever
Hoarseness
Varying degree inspiratory stridor
“Barking” cough
Tachypnea, tachycardia, cyanosis (severe cases)
“Steeple” sign on x-ray examination
Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”
Presentation of “Croup” on x-ray examination
Steeple” sign
Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”
Presentation of “Steeple” sign
See picture
Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”
Treatment of “Croup”
6% require hospitalization
Cool, humidified mist & O2 therapy (tent)
Racemic epinephrine (2.25%) by nebulizer
Steroids (controversial)
Current opinion: short courses beneficial
Intubation for pulmonary toilet/suctioning if thick secretions present
Management of PICU/<u>extubation similar to epiglottis</u>
Difference:<u> PPV with bag/mask may be beneficial</u>
Pediatric Airway Emergencies - Epiglottitis
Organism - Age - Onset:
See picture
Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”
Organism - Age - Onset:
See picture
Pediatric Airway Emergencies - Epiglottitis
Region affected - Lateral Neck X-ray - Clinical presentation & Treatment
See picture
Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”
Region affected - Lateral Neck X-ray - Clinical presentation & Treatment
See picture
Pediatric Airway Emergencies
Major cause of morbidity/mortality
Foreign Body Aspiration
Most deaths: at time of aspiration
Mortality rate = 0% if child arrives to ER alive
Pediatric Airway Emergencies - Foreign Body Aspiration
Foreign Body Aspiration mostly occurs at what age?
Between 7mos & 4 y/o
Pediatric Airway Emergencies - Foreign Body Aspiration
Most common site of occurence of Foreign Body Aspiration
Proximal airway (75%)
Right main-stem bronchus
Pediatric Airway Emergencies - Foreign Body Aspiration
Most common item responsible for Foreign Body Aspiration
Food particles
Pediatric Airway Emergencies - Foreign Body Aspiration
Clinical presentation of Foreign Body Aspiration
Witnessed
Choking, coughing, cyanosis
Unwitnessed Suspected (ER)
↓ Breath sounds - Tachypnea - Refractory wheezing - Fever
Pediatric Airway Emergencies - Foreign Body Aspiration
What will Radiological exams of Foreign Body Aspiration reveal?
90% are radiolucent
Postobstruction air trapping/emphysema
Unilateral infiltrates/atelectasis
Pneumonia
Pediatric Airway Emergencies - Foreign Body Aspiration
Treatment of Foreign Body Aspiration
Bronchoscopy - Laryngoscopy
Emergency situation requiring removal in the OR only
Pediatric Airway Emergencies - Foreign Body Aspiration
Picture showing X-ray presentation of Foreign Body Aspiration
See picture
Anesthetic considerations/management of Foreign Body Aspiration
T/F: GIVE SEDATION/PREMED BEFORE REMOVAL OF FB
FALSE
NO SEDATION/PREMED BEFORE REMOVAL OF FB
Anesthetic considerations/management of Foreign Body Aspiration
Spontaneous vs. Controlled ventilation
…
Anesthetic considerations/management of Foreign Body Aspiration
Spontaneous Ventilation considerations w/ Foreign Body Aspiration include:
Inhalation induction (if NP0) with Sevo/100 % O2
SV maintained
VC sprayed with topical lidocaine (2% school age, 1% small infant)
Must obtain adequate depth of anesthesia to prevent coughing/bucking
Intubate and suction stomach
Give airway to surgeon: replaces ET with ventilating bronchoscope
Gas/O2 provided by side arm of bronchoscope
Anesthetic considerations/management of Foreign Body Aspiration
Advantages of Spontaneous Ventilation
Better airflow distribution
Uninterrupted ventilation
Assess ventilatory mechanics after removal FB
Anesthetic considerations/management of Foreign Body Aspiration
Disadvantages of Spontaneous Ventilation
Risk of patient movement
Prolonged emergence
Anesthetic considerations/management of Foreign Body Aspiration
Controlled ventilation considerations w/ Foreign Body Aspiration include:
RSI with OET intubation
Maintenance: Propofol, remifentanil gtt, short-acting muscle relaxant
Ventilation performed in concert with surgeon
Apneic ventilation: Periods of hyperventilation interspersed with brief periods of bronchoscopy
Jet ventilation: RR normal, duration of breath guided by chest expansion/pulse oximetry, allow for adequate exhalation essential
Anesthetic considerations/management of Foreign Body Aspiration
Advantages of Controlled ventilation
Rapid control of airway
No patient movement
Decreased anesthetic requirements
Anesthetic considerations/management of Foreign Body Aspiration
Disadvantages of Controlled ventilation
Ventilation interrupted
Depth of anesthesia unreliable (if using gases)
Risk of FB dislodgement distally
Barotrauma with hyperinflation
Anesthetic considerations/management of Foreign Body Aspiration
How and why would you convert a Partial obstruction into a complete obstruction during bronchoscopy
Push object into mainstem bronchus to allow life saving ventilation of opposite lung
